Minnesota Hospital Association


February 04, 2015

Nurse Staffing Plan Disclosure Act: Implementation of the law and the MDH study

The Nurse Staffing Plan Disclosure Act of 2013 required: 1) the public reporting of hospital staffing levels and 2) a study by the MN Department of Health on the correlation between nurse staffing levels and patient outcomes.

  • Public reporting of staffing levels
    All Minnesota hospitals must prepare an annual nurse staffing plan to be posted on the Minnesota Hospital Association’s quality website, www.mnhospitalquality.org, beginning Apr. 1, 2014.
  • Hospitals are required to, on a quarterly basis, report how their actual nurse staffing levels and patient census compared to their nurse staffing plans. This information has been posted online since July 1, 2014 and is updated quarterly.

MDH’s nurse staffing and patient outcomes study

The law describes the study this way:

"The Department of Health shall convene a work group to consult with the department as they study the correlation between nurse staffing levels and patient outcomes. This report shall be presented to the chairs and ranking minority members of the Health and Human Services Committees in the House of Representatives and the Senate by January 15, 2015.”

  • The Minnesota Department of Health convened a Nurse Staffing and Patient Outcomes Study Workgroup (workgroup) comprised of three hospital representatives, three Minnesota Nurses Association (MNA) representatives and other individuals with backgrounds in higher education, patient safety, and one consumer representative. The work group held five public meetings.
  • From the beginning of the work group, MHA representatives stressed that MDH could do the study using already publicly reported quality information. Given the depth and breadth of quality data that is already publicly reported, MHA asked MDH not to seek additional data from hospitals. In an effort to collaborate with MDH, MHA communicated in person with MDH staff and with the Commissioner and in writing on at least a half a dozen occasions.
  • MDH asked 39 hospitals for data from 2013. After surveying its members about whether it was possible to collect the staffing data from 2013, MHA informed MDH that for many of its members it would be impossible to provide the data MDH was seeking because the new law went into effect in 2014 and therefore hospitals had not been collecting the staffing data MDH wanted in 2013. In addition, MHA informed MDH that conducting the study based on a subset of MN hospitals was not called for in the legislation.
  • MDH also sought to match patient outcomes to staffing levels, however, publicly available outcomes data are exclusively collected at the hospital level, not at the unit level. Obtaining more granular staffing data at the unit and even shift level does nothing to change the fact that reporting of quality outcomes are at the hospital level. In other words, even with staffing data by unit, MDH would not have outcome or quality data for the unit.

MDH’s Nurse Staffing and Patient Outcomes report

As part of its study, MDH reviewed a number of studies on nurse staffing and patient outcomes. In his cover letter to legislators, Commissioner of Health Ed Ehlinger states:

“At this point, available studies do not prove causal relationship, or indicate that changes in patient outcomes are solely the result of nurse staffing decisions; they also do not identify points at which staffing levels become unsafe or begin to have negative effects on outcomes.” 

Further, the report states:

“While the literature has demonstrated the correlation between nurse staffing volumes and certain outcomes, it has not yet established an increase in nurse volume will inevitable product [sic] changes in outcomes – or the pretense of a causal relationship. In addition, the published evidence doesn’t provide specific nurse staffing levels that will lead to certain patient outcomes, or suggest particular staffing models that might be more effective in improving patient outcomes. ” p. 4.

“…there have been no randomized controlled trials or studies using random assignment of nurse staffing levels to certain hospitals to study patient outcomes. Without this specific approach, it is not possible to determine the most appropriate staffing configuration or at which level nurse staffing is correlated with better or worse patient outcomes.” p. 5.

Hospitals agree that staffing is important to quality

  • Quality and safe patient care is delivered by a care team that includes more than nurses – physicians, nursing assistants, therapists such as PT or respiratory, dietitians, and more.
  • Conducting his own analysis of hospital quality measures and staffing, a health and quality expert from the University of St. Thomas showed that there is only a weak correlation, and it is not possible to determine the ideal mix or number of care providers -- including all of the other members of the care team such as physicians or nursing assistants -- for a given workload of patients.
  • The condition of the patient, the experience of the care team, and the mix of the care team has as much to do with patient outcomes – if not more – as the number of nurses.
  • There are hundreds of academic studies regarding nurse staffing that do not reach a definitive conclusion of the number of nurses needed to achieve the best patient outcomes. There are studies that also look at other factors such as the length of shifts, the experience and education level of the nurse, and the skill mix of the care team as having as much or more to do with patient outcomes.
  • However, despite multiple studies by academic researchers throughout the country, no one has identified a definitive staffing level required to ensure quality outcomes for patients. Instead, staffing is inherently dynamic and constantly adjusted based on factors such as: the particular needs of the individual patient; the experience level of the nursing staff, physicians and other members of the care team; the physical layout of the specific unit; and a whole host of other variables. Moreover, staffing levels are just one factor in a multitude of drivers that determine patient outcomes.

The Minnesota Nurses Association is critical of the MDH report because it wants support for mandated nurse staffing ratios. Below are the MNA’s claims and MHA responses:

Claim: MNA is claiming that Minnesota hospitals broke the law. Did Minnesota hospitals comply with the law?

MHA response: Yes. The 2013 law requires hospitals to report their staffing plans annually and their actual staffing statistics quarterly beginning in 2014. Hospitals fully comply with this new reporting requirement and all of our information is available on the www.mnhospitalquality.org website. Nothing in the law required hospitals to provide the volumes of daily, unit-level staffing data from 2013 that the Minnesota Department of Health requested in its study.

Claim: Minnesota hospitals did not cooperate with the MDH study.

MHA response: Representatives of Minnesota’s hospitals actively participated in MDH’s advisory group for this study. There were three hospital representatives on the study work group consulting with the Department. In addition, MHA provided MDH with sample analytical frameworks for completing the study with publicly available data. In fact, MHA had a health care economist from the University of St. Thomas conduct an independent study using publicly available data for all Minnesota hospitals. MHA provided the results of that study to MDH for MDH to use to guide its own work or to incorporate into its report to the legislature.

Claim: Hospitals refused to provide the data required by the law.

MHA response: Almost all hospitals no longer retained or could not reproduce the data requested by MDH without extraordinary burden. Hospitals provided quick, responsive information to MDH documenting that they could not collect or recreate the data MDH planned to request.

MDH did not request simple staffing information. Instead, it asked a select number of hospitals to disclose how many registered nurses (RNs), how many licensed practical nurses (LPNs), and how many unlicensed assistive personnel worked at least 50 percent of their time on each unit of the hospital for each day of 2013. While hospitals could produce information about how many of these professionals worked on a particular day, for example, the overwhelming majority of hospitals would have to undertake an incredible amount of work to recreate which units each caregiver worked on for each day. For some, the unit-level staffing assignment information no longer exists.

As documented in MDH’s report, both MHA and MNA objected to the department’s attempt to collect data from a subset of hospitals when all hospitals are required to report their staffing data.